Health Care

The ACFE has found that large, noteworthy fraud cases — like Enron or Bernie Madoff — will live on in infamy and can provide valuable lessons for fraud fighters. That’s why we, along with input from our members, have selected these five stories of 2018 as the most scandalous frauds of 2018. We chose the stories based on money lost, lives impacted and relevance to the anti-fraud profession.

Dr. Sam Foote didn’t plan to be a whistleblower. He didn’t even plan on being a doctor, let alone one in the U.S. Veterans Affairs Department (VA) during the height of scandal in Arizona. But the moon landing in 1969 altered the course of his future and potentially the lives of thousands of U.S. veterans.

See something, say something

Organizations must fully examine internal control functions when they detect deviations from expectations based on past experiences. They must examine the web of controls in the entire supply chain — from vendors to customers — to detect or investigate abnormalities.

Letters from prison tell the story of a $1.65 million insurance fraud

Fictitious insurance claims filed by Joshua Miller, owner of a Syracuse hearing-aid dispenser, cost the New York state insurance fund $1.65 million. Learn how he, and others, edged the system to commit the crime.

Theranos

Although the Theranos saga is far from over — the company is fighting multiple lawsuits and regulatory actions — I’ll limit my analysis to the “Mad Money” interview. It provides us with valuable insights into how we can apply our interviewing skills as fraud examiners not only to the standard-type fraud examinations we deal with daily but also to unusual high-profile “personality cases” like Theranos.

Audio recording physician exams

Here’s a simple way to help prevent health care fraud. Patients, with their doctors’ consent, can audio record doctor visits with their smartphones. Audio recordings can verify bills submitted for health care services. And medical providers can upload and store audio files in patients’ electronic medical records to help ensure the veracity of physicians’ diagnoses and interventions.

Nuts & bolts of health care fraud examinations

Health care fraud examinations can be laborious. Discovery of evidence can be elusive. You need the most reliable sources and resources. Here’s a practical sampling of some of the best places to start from a fraud examiner who’s worked scores of cases.

Health care analytics

Why is it such a challenge to control opioid abuse? It’s a combination of the sheer number of pharmacy claims and the woefully outdated manual methods used to review them. The slow, labor-intensive process of manually inspecting spreadsheets, even those generated from a database, can lead to false positives. It also uses time and resources that should be spent tracking down those who are actually committing FWA. The sheer size of data can cause processing time and infrastructure issues, and overwhelm the system.

Healthcare Fraud Investigation Guidebook

Learn how to both detect and investigate health care fraud.

Greedy company president sinks family-owned firm

In early 2013, employees of a trucking company were trying to use their health care benefits, but their doctors and hospitals were rejecting them. Their insurance carrier was denying their claims. Their paychecks showed their employer had been deducting their shares of medical insurance premiums, but their insurance cards were worthless.

Identifying prescription abuse via fraud analytics

People are dying from drug overdoses in increasingly alarming numbers. They’re from poor, middle-class and wealthy communities. The deaths have jumped in nearly every county just in the U.S. — driven largely by an escalating increase in addiction to prescription painkillers and heroin.

Statistical sampling

With large caseloads and limited resources, fraud examiners need to be able to effectively and efficiently complete fraud examinations. A case is easier, of course, when we’ve isolated the fraudsters, discovered what they’re doing and how they’re committing the crimes.